Healthcare reform & psychiatry

July 31st, 2009

The recent debates over U.S. healthcare reform are long overdue, yet still sadly inadequate. (The discussion is about health insurance, actually, not the care itself. But I titled this post “healthcare reform” since that is what everyone is calling it.) There is no need to rehash the plentiful evidence that the current system is broken: millions of uninsured, job lock to maintain health coverage, unwarranted claim delays and denials, whole industries devoted to medical paperwork and reimbursement, and the near impossibility, given a pre-existing condition, of purchasing non-employment based insurance at any price. Hardly anyone across the political spectrum argues for the status quo.

The national debate centers on how to provide universal, or universally available, coverage to all Americans. Some argue that with proper incentives, private insurers could cover everyone. Similar to health coverage in the Netherlands, this proposal aims to preserve the private insurance industry and competition in the marketplace. Others argue that health care does not follow classic supply-demand principles, and that competition among private insurers has not controlled costs. A publicly funded, government-sponsored option is preferred to remove the profit motive and gain efficiency through standardization.

Universal health coverage is the norm in virtually all developed countries. I believe Turkey and the U.S. are the only remaining exceptions. Some nations, Britain for example, have nationalized health care — doctors are government employees. Others, like Canada, use public funds to pay doctors in private practice, much as Medicare currently operates in the U.S. These systems are not perfect. In particular, there are longer waiting times for elective procedures, sometimes on the order of months. But surveysrepeatedly show that citizens (and doctors) of these countries are happier with their health services than Americans are with ours. And studies also show their health outcomes are the same or better than ours, for far lessmoney.

There are many places to read about health insurance reform that do a better job than I can (e.g., here). From my reading, I believe a single-payer plan such as those in Australia, Canada, and Taiwan would greatly improve health care in the U.S., while preserving patients’ ability to choose their own doctors, and also doctors’ ability to work in the private sector. It’s a pity this option, so popular across the globe, is a political third-rail here. In my view, publicly funded health insurance (think Medicare) is no more “socialist” than the public funding of highways, police departments, and firefighters.

In a nutshell, that’s my view of publicly funded health insurance in general medicine and surgery. But what about psychiatry in particular?

Universal coverage would be a boon for the seriously mentally ill. Schizophrenia and severe chronic mood disorders render many sufferers unemployable and ineligible for private insurance. Some eventually qualify for Medicare and/or Medicaid, the limited forms of public health insurance that already exist. The additional stigma attached to using public programs due to severe disability would abate if public health insurance became a mainstream reality. Others with debilitating but less severe forms of mental illness do not qualify for Medicare or Medicaid, but cannot maintain private insurance due to frequent job loss, chaotic lives, depression, and so forth. The affordability of care and treatment is a constant stress atop an already stressful existence.

Universal health coverage would change all that (see this report from the California Endowment). Canadians talk about their comfort in knowing their friends, acquaintances, coworkers — fellow citizens — have access to health care regardless of circumstance. Healthy Americans might feel this way, too, when the chronically mentally ill among us are assured access to care.

At the other end of the psychiatric spectrum are relatively healthy individuals who seek psychotherapy for help in living a life that is basically stable, but is unfulfilling, frustrating, anxiety-laden, or sad. In the U.S., most health insurance, private or public, limits coverage for this type of treatment. Many private plans cap the number of treatment sessions to 20 or fewer per year; Kaiser Permanente additionally requires that a mental health professional “believes the condition will significantly improve with relatively short-term therapy.” Medicare does not cap the number of visits, but covers only half its “allowed fee” — the patient or supplemental insurance pays the other half.

It should be noted that traditional dynamic psychotherapy, the kind I do, considers it beneficial when the patient pays for therapy himself. Directly paying for therapy focuses the dynamics between patient and therapist by excluding distracting intermediaries. It matters more (to both parties) that the patient gets what he or she is paying for. Sometimes patients express unstated feelings toward their therapist in how they pay their bill; this can be interpreted as transference, moving the treatment forward. Moreover, dynamic psychotherapy is an intensely private undertaking: Many patients choose to forgo insurance coverage even if they have it, to avoid a public record of the treatment, or the need to document it with third parties.

All that said, many more people can benefit by psychotherapy than can afford to pay for it directly. A universal health plan that covered therapy in a substantial way (say, as Medicare does now) would make this service available to many who could not receive it before. Third-party payment issues are handled all the time in dynamic therapy even now. And not all therapy is psychodynamic; I know of no concerns regarding CBT (cognitive behavioral therapy), for example, being paid by third parties.

In short, U.S. healthcare — more accurately, health insurance — reform that universally covered mental health treatment would revolutionize care of the mentally ill in this country. Benefits could be as visible as fewer homeless on the streets and in the jails, as subtle and pervasive as a comforting sense that Americans care about each other both in body and spirit. I hope we have the will and the wisdom to make it happen.